OUTPATIENT PRAC EXAM.pdf

OUTPATIENT PRAC EXAM Outline Assessed on their ability to select and perform effective treatment strategies, demonstrate safe manual handling, organize environment and use equipment safely and effectively and interpret clinical assessment findings Examiner...

OUTPATIENT PRAC EXAM Outline Assessed on their ability to select and perform effective treatment strategies, demonstrate safe manual handling, organize environment and use equipment safely and effectively and interpret clinical assessment findings Examiner will randomly select the case study for each student The content to be assessed includes all practical skills learnt (excluding paediatric content) You will be asked to perform: o Two appropriate assessment techniques* that you would include when assessing the patient. o Two appropriate management techniques that you may include when managing the patient (e.g. education, exercise or manual therapy). o *If you perform active movements, you will be expected to perform at least 3 (including overpressures) o *if you perform palpation of the spine (e.g. PAIVMs) you’ll be expected to palpate at least 3 spinal levels // DON’T HAVE AX AND TX AS SAME TECHNIQUE Conditions List: 1. Cervicogenic headache 2. Non-specific neck pain (with or without somatic referred pain) 3. Work related neck pain 4. Vestibular basilar insufficiency 5. Cervical spine radicular pain +/- radiculopathy 6. Neuromechanosensitivity (upper limb) 7. Non-specific thoracic spine pain (with or without somatic referred pain) 8. Non-specific lower back pain (with or without somatic referred pain) 9. Spinal stenosis 10. Lumbar spine radicular pain +/- radiculopathy 11. Neuromechanosensitivity (lower limb) 12. Red flag conditions 13. Pelvic girdle pain (for example pain arising from the sacroiliac joint pain) Please note that you may not need to treat all conditions e.g. red flag/VBI, the examination in this case would involve you recognising/assessing and delivering education.  Table of Contents Outline.................................................................................................................. 1 Conditions List:...................................................................................................... 1 1. Cervicogenic headache.............................................................................................2 2. Non-specific neck pain (with or without somatic referred pain)..................................3 3. Work related neck pain..............................................................................................4 4. Vestibular basilar insufficiency..................................................................................4 5. Cervical spine radicular pain +/- radiculopathy..........................................................5 6. Neuromechanosensitivity (upper limb)......................................................................6 7. Non-specific thoracic spine pain (with or without somatic referred pain)....................7 8. Non-specific lower back pain (with or without somatic referred pain).........................8 9. Spinal stenosis..........................................................................................................8 10. Lumbar spine radicular pain +/- radiculopathy..........................................................9 11. Neuromechanosensitivity (lower limb)................................................................... 10 12. Red flag conditions................................................................................................ 11 13. Pelvic girdle pain (for example pain arising from the sacroiliac joint pain)............... 11 1. Cervicogenic headache Info: Headache results from C/Sp (referral pain) – most associated with C/Sp stiffness/neck pain Pain may radiate to forehead, orbital region, temples or ears Decreased or limited cervical ROM Mostly unilateral  C1-3 share same nerve supply as occipital area → stiffness = pain in head Positional or associated with particular movement Very consistent and specific sx during ax Duration: couple hours during aggravating activity Prognosis: complete recovery expected in most cases, but underlying chronic conditions prognosis is gaurded Assessments Treatments What to look for in physical exam Education - Pain reproduced with overpressure over affected Education re. ‘Your next posture is your best posture’ upper cervical area Address provocative postures, posture cues, ergonomics - Multiple upper cervical joint restrictions or Scap depression, Forward head posture, AA muscle use dysfunctions Cold or hot pack - Atleast 1 of the following Cervical pillow/supportive mattress o Resistance to or limitation of passive neck Traction and stretching movements Stress management and relaxation therapy, posture and o Changes in neck muscle contour, texture, ergonomic evaluation tone, or response to actuive and passive stretching PAIVMs → Improve joint mobility and  pain o Abnormal tenderness of neck muscles C0-3 → unilat PA, transverse glide ( rot) Physical Examination Craniocervical flexion test (CCT) → distinguish cranio vs Exercise migraine and/or tension (these two won’t have  in Give self an upper cut isom (flex) function/strength during test) – balloon cuff one 4pt kneeling pushup (ext) Cervical Flexion Rotation Test (CFRT) → Norm = 45 deg each direction. Cervico would be expecting  15 deg or Other appropriate tests but not for exam difference of 10+ deg L to R STM → Ant Scalenes, UT, suboccipital muscle trigger PAIVMs for C0-3 unilat PA → Hypomobility, pain point to begin (or if CCF is  d/t soft tissue restriction) reproduction, different comparing sides. Other types of Bow and arrow for T/SP headaches will be more diffuse sx, less specific, just Stretches → upper cervical stretch (OP into upper C/F) report soreness Double chins Other appropriate tests but not for exam C/Sp ext using hand back of head Postural assessment → doesn’t help with diagnosis, Shrugs for upper trap depression could just be normal position ROM → rotations, LF AROM → C0-3 rotation 60% of normal, C0-3 F/E 33% of normal → could just be stiff neck Neck flexion strength test 2. Non-specific neck pain (with or without somatic referred pain) Assessments Treatments Physical Examination Education ROM → measure with tape measure → + OP Advice to stay active, prognosis info, reassurance, self- o F: reach chin to chest? – gap between management strategies o E: sternal notch to chin Exercise o Rot: chin to acromion Restore neuromuscular control of deep neck flexors -  o LF: ear to acromion pain and disability o Cranio-cervical flexion Double chins o Cranio-cervical extension Give self an upper cut isom o Cranio-cervical rotation 4pt kneeling pushup Combined movements Bow and arrow for T/SP o Ext + Rot, Ext + LF, F + LF, F + Rot Mobilisations  PAIVMs → central PA, unilat PA, transverse Central PA, unilat PA and Transverse glide, cervical PPIVMs → cervical lateral flexion distraction Mulligans → rotation MWM, MVM flexion Determine from somatic pain? STM Trigger point ant scalene, upper traps, suboccipital 3. Work related neck pain Assessments Treatments ROM → measure with tape measure → + OP Education o F: reach chin to chest? – gap between Advice to stay active, prognosis info, reassurance, self- o E: sternal notch to chin management strategies o Rot: chin to acromion Work environment o LF: ear to acromion Ergonomics o Cranio-cervical flexion Postural o Cranio-cervical extension Exercise o Cranio-cervical rotation Restore neuromuscular control of deep neck flexors -  Combined movements pain and disability o Ext + Rot, Ext + LF, F + LF, F + Rot Double chins PAIVMs → central PA, unilat PA, transverse Give self an upper cut isom PPIVMs → cervical lateral flexioneness 4pt kneeling pushup Bow and arrow for T/SP Functional movements related to job Less so? Mobilisations Central PA, unilat PA and Transverse glide, cervical distraction Mulligans → rotation MWM, MVM flexion STM Trigger point ant scalene, upper traps, suboccipital 4. Vestibular basilar insufficiency Insufficient blood supply to the brain due to disruption to blood flow supplied by the carotid or vertebral artery Symptoms o Vertigo, dizziness, unsteadyness and giddiness o Headache or neckpain that is ‘worse or different to ewhat they have had before’ o Other possible symptoms ▪ Visual disturbance ▪ Facial numbness or paresthesias ▪ Dysphagia, dysarthria, hoars ▪ Drop attacks ▪ Hemiparesis Prognosis: o Chance of death 90% of patients can be treated conservatively and show improvement over 6-8 weeks o If no improvement within 6 weeks consider surgical evaluation Manual therapy  Tractions PAIVMs → ? Sliders and tensioners → median nerve, ulnar nerve Exercise → dosage based on their lifestyle All exercises should be performed without pain but post exercise soreness is expected Give self an upper cut isom 4pt kneeling pushup Chin tuck Other appropriate treatment but not for exam Chin tuck and flexion Supine chin tuck Scapular retraction Bow and arrow for T/SP Other appropriate tests but not for exam Four tests Check ROM → (< 60 deg rotation to affected side) Spurlings → E/SF/Rot + axial compression. Test both sides – reproduction of arm symptoms Traction → arm pain goes away Median nerve neurodynamic → positive If top 3 positive = 70% rule in C/sp rad. If all positive = 92% rule in. Shoulder abduction (relief) test → positive when complaints reduce/disappear Arm squeeze test → painful in mid-section of upper arm (quite high Sn, Sp) 6. Neuromechanosensitivity (upper limb) Neurodynamic test → series of movements that place consecutive load on the nervous system – looking at how peripheral nerves respond to mechanical stress – trying to reproduce Pt’s symptoms What is an abnormal test (positive test) o Reproduction of patients symptoms (MUST) o Structural differentiation gives a neural result (MUST) o Range of motion may be reduced (NOT A MUST) (might not be reduced in range assessed) What is not an abnormal test o Because the test was not relevant (sensitivity/specificty) o Contralateral testing → symmetrical response – Pt normally tight o Does not reproduce the patients symptoms Assessments Treatments Palpate onto nerve Treatment techniques o Median → cubital fossa (medial side of Sliders: biceps tendon), carpal tunnel o Aim to induce sliding of the peripheral nerves o Ulnar → cubital tunnel at elbow, Guyon’s in relation to their surrounding structures with canal between pisiform and hook of hamate, a minimal increase in nerve strain under bicep muscle o Simultaneous lengthening of the nerve bed at o Radial → snuff box, deltoid tuberosity one joint while shortening the nerve bed over Neurodynamic test – maybe 2? → median and another joint another o For more irritable pts Tensioners:  o Aim to  nerve strain by simultaneously elongating the nerve bed at multiple joints o For less irritable, in persistent px state pts IDK WHAT OTHER TYPE. EDUCATION? ANOTHER EXERCISE, PPIVMS @ location of the nerve Myotome/sensation/reflexes compression? 7. Non-specific thoracic spine pain (with or without somatic referred pain) Assessments Treatments Active movements (SOEOB) → Flexion, extension, rotation, lateral flexion → + OP − T1, T2 spinous processes: plus one finger-width Combined movements → Flexion + rotation. − T3,T4 spinous processes: plus two finger-widths Extension + rotation. Any other functionally reported − T5-T8 spinous processes: plus three finger- movement (below) widths Other functional movements tests → Unilateral bicep − T9, T10 spinous processes: plus two finger- curl, Wall push up, Single leg stance/single leg squat, widths Prone arm lift, 4-point kneeling, Sitting reposition test, − T11, T12 spinous processes: plus one finger- Inspiration width PAVIMs → Unilateral PA (transverse process), central PA Exercise (spinous process), PA costo-transverse and Cat/cow?, stretch pec, scapula retractions, rows costovertebral joint (indirectly). PPIVMs → Flexion, extension, rotation PAVIMS → To increase unilateral rotation ROM ROM → measure with tape measure → + OP Transverse glide o F: reach chin to chest? – gap between Unilateral PA o E: sternal notch to chin Costovertebral PA o Rot: chin to acromion Rotation PPIVM o LF: ear to acromion Thoracic Rotation MWM o Cranio-cervical flexion Transverse glide: T1-T4 MWM (cervico-thoracic region) o Cranio-cervical extension Transverse glide: T1-T4 MWM with rotation (cervico- o Cranio-cervical rotation thoracic region) Combined movements To increase extension ROM o Ext + Rot, Ext + LF, F + LF, F + Rot Central PA PAIVMs → central PA, unilat PA, transverse Thoracic PPIVM PPIVMs → cervical lateral flexion To increase flexion ROM Thoracic PPIVM (flexion) Determine from somatic pain? Thoracic superior glide (T1-4) PPIVMs?  8. Non-specific lower back pain (with or without somatic referred pain) Non- ‘Every time I move into this position, I feel this pain/pain goes away’ (clear pattern of movement) Specific Also, could be pain not related to movement (indicator of nociplastic pain but could just be more complex) Stiffness, Pain comes and goes, Mechanical related pain, Better with rest, No previous injury, Stress related Specific Pain/numbness/P&Ns/shooting/radiating down leg Pathology Neuro examination – reflex, sensory exam (dermatomes), motor exam, Bilateral leg pain or unilateral leg pain Serious TUNAFISH – red flags Pathology Assessments Treatments ROM → F, E, LF, Rot Education Neuro ax → SLR, slump, myotome, sensory, reflexes, Pain neuroscience education, natural hx, advice to stay Babinski/clonus active, expectations PAIVMS → find L4 (iliac crest and across) Mobilisations o PA central → pain? Is vertebrae segment Think about derangement, dysfunction, postural normal? Hyper/hypo? PAIVMs → Central PA and Transverse glide o PA unilat/transverse → pain? Is facet jt segment PPIVMs → Mulligan → for localised, diffuse pain,  ROM normal? Hyper/hypo? and pain in the direction you are trying to treat PPIVMs → F, E, Rot, LF Manipulation → Lumbar distraction → for OA,  ROM, MMTs radiculopathies, belt around gastroc Functional tests → endurance position, lift heavy Exercise object, perform specific movement Is the best treatment option for patient with low back pain. They all work, but core strengthening, Pilates, Determine from somatic pain? functional restoration and McKenzie had better effects McKenzie → o E → prone – puppy prone - cobra, cat/cow - bird dog, pelvic neutral, plank, superman, DL bridge Core exercises and Pilates Motor control Graded activity Mobility exercises 9. Spinal stenosis Multilevel degenerative changes where there is narrowing of the spinal canal. Love flexion (vertebral column open -  compression on nerve), love sitting, hate doing anything else (walking, standing), lean over the trolley. Common in 75+. Bilateral ant/post thigh pain Stenosis doesn’t typically follow a nerve root, more whole leg Cook clinical decision rule (at least 3/5 positive) Age > 48 years, bilateral symptoms, leg pain more than back pain, pain during walking/standing, pain relief upon sitting Lumbar stenosis prognosis 90% of patients will remain stable or improve without treatment Assessments Treatments ROM → F, E, LF, Rot (Reproduce pain on extension) Neuro ax → SLR, slump, myotome, sensory, reflexes, I DON’T KNOW Babinski/clonus PAIVMS → find L4 (iliac crest and across) Lumbar stenosis  o PA central → pain? Is vertebrae segment - Education normal? Hyper/hypo? o Avoid extension movements as they will o PA unilat/transverse → pain? Is facet jt segment exacerbate symptoms normal? Hyper/hypo? o Prognosis PPIVMs → F, E, Rot, LF - Flexion exercises > target lumbar lordosis, MMTs paraspinal/hamstring flexibility and abdominal Functional tests → endurance position, lift heavy muscles object, perform specific movement o Knee to chest manoeuvres o Pelvic tilts o Wall standing lumbar flexion 10. Lumbar spine radicular pain +/- radiculopathy Radicular pain → referred pain from a spinal nerve with no nerve root compromise (sharp, shooting pain) Radiculopathy → signs of nerve root compromise ( sensation,  reflex,  myotome weakness) - Caused by lesion or disease Somatic referred → pain from a musculoskeletal origin (dull aches, certain positions Pain worse in leg than back Pain worsens on cough/sneeze/strain (Sn 40%, Sp 77%) Malalignment/scoliosis (lateral shift) (Sn 39-64%, Sp 62-89%)  reflexes (achilles and patella tendon) (Sn 14-61%, Sp 60-93%) Assessments Treatments Special tests (2 main + historic ones) Prognosis → Favourable → 85% recovers within 12 mo. (Crossed) SLR → Hip MR + Add, Knee E, lift leg, px 50% at 6 weeks, 70% at 3 mo reproduction (Crossed = SpPIN, normal SLR = SnNOut) Slump test Short term → massage for lumbar or cervical paraspinal Bell test → pressure applied with thumb between tone, heat packs, hot showers spinous process L4-5, L5-S1 (not Sn because LBP also Manual therapy → traction, PAIVMs would be sore) Exercise → effective Hyperextension test → prone → cobra →  sx (might o Motor control exercises not happen, can’t rule in/out) o McKenzie exercises → prone – puppy prone - Kemps test → E, LF, Rot + axial pressure (like spurlings, cobra, cat/cow - bird dog, pelvic neutral, plank, pretty much a combined movement) superman, DL bridge Myotome, sensory, reflex Sliders and tensioners → slump Stretching Education/advice to stay active → effective Go for imaging if complete absent myotomes  11. Neuromechanosensitivity (lower limb) Neurodynamic test → series of movements that place consecutive load on the nervous system – looking at how peripheral nerves respond to mechanical stress – trying to reproduce Pt’s symptoms What is an abnormal test (positive test) o Reproduction of patients symptoms (MUST) o Structural differentiation gives a neural result (MUST) o Range of motion may be reduced (NOT A MUST) (might not be reduced in range assessed) What is not an abnormal test o Because the test was not relevant (sensitivity/specificty) o Contralateral testing → symmetrical response – Pt normally tight o Does not reproduce the patients symptoms Assessments Treatments Palpate onto nerve Treatment techniques Sliders: o Aim to induce sliding of the peripheral nerves in relation to their surrounding structures with a minimal increase in nerve strain o Simultaneous lengthening of the nerve bed at one joint while shortening the nerve bed over another joint o For more irritable pts Tensioners: o Aim to  nerve strain by simultaneously elongating the nerve bed at multiple joints o For less irritable, in persistent px state pts Myotome, sensory, reflex Neurodynamic test 1. Straight a) Tibial nerve – DF + EV + Pron leg raise b) Sural nerve – DF + INV c) Peroneal nerve – PF + INV 2. Slump 1) Slump forward at T/Sp and L/SP 2) Active C/Sp F 3) Passive overpressure of triple E (forearm) 4) Active knee E 5) Passive DF 3. Prone 1) Grasp lower leg just above ankle knee bend 2) Fully flex knee while stabilising hip and L/Sp  12. Red flag conditions Pathology Incidence Symptoms and Diagnostic accuracy Cancer 0-5% Unexplained weight loss (